PURPOSE: To compare the feasibility and safety of three approaches for bilateral adrenal venous sampling (AVS) and their influence on the outcomes of adrenalectomy for dominant lateral primary aldosteronism (PA). METHODS: 182 PA patients who underwent AVS at Fuwai Hospital between January 2022 and March 2024 were enrolled. According to the puncture access, patients were divided into three groups: simultaneous AVS via antecubital approach group (Group A, N = 48), simultaneous AVS via femoral approach group (Group B, N = 44) and sequential AVS via antecubital approach group (Group C, N = 90). The baseline data, procedure parameters, success rates, complication rates and follow-up data were analyzed. RESULTS: The baseline characteristics did not differ significantly among three groups (all P >
0.05). The procedure time (18.9 ± 7.4 min vs. 25.2 ± 7.5 min
P <
0.001) and fluoroscopy time (7.1 ± 3.8 min vs. 10.8 ± 6.2 min
P <
0.001) were shorter in Group A than in Group C. However, there was no significant difference between Group A and B (all P >
0.05). The bilateral sampling success rates in Groups A, B and C were 93.8%, 93.2% and 91.1%, respectively, which were not significantly different (P = 0.936). One (0.5%) adrenal haematoma was recorded in Group B. The complete clinical success rate (P = 0.894) and complete biochemical success rate (P = 0.954) were not significantly different in patients with dominant lateralization who underwent adrenalectomy. CONCLUSION: This study revealed that three approaches for AVS are safe and feasible, with similar outcomes after adrenalectomy. Simultaneous AVS via antecubital approach might be a better choice considering its shorter procedure and fluoroscopy time and comfort.